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Cookie Cutter Therapies

The study of Asian American mental health emerged in the 1970s due to the widespread lack of appreciation among mental health professionals of the importance of culture in effectively treating many Asian American clients. In the ’70s, I believe the majority, or a least a distressingly large minority, of professionals assumed that precisely the same therapies that were beneficial to many upper-middle-class, white Americans would be equally effective for treating immigrant Asian Americans. In recent years, however, it has become clear to most that cultural sensitivity should be a major consideration in the treatment of Asian Americans.

Cultural sensitivity is especially crucial in treating those who were born and raised in an Asian country. Methods that work for white Americans clearly do not always prove helpful in the treatment of Asian Americans. For example, therapists are taught that if they demonstrate visibly and audibly their emphatic resonance with the emotionally distressed client that enhanced conversation will result. Yet, with a Japanese immigrant client, the therapist’s visible empathic tuning with the client can stop the client’s flow of speech in its tracks. In Vietnamese, there is no good translation for the English word “depression”; a culturally knowledgeable therapist who speaks Vietnamese needs to engage a depressed Vietnamese client in treatment by focusing on the client’s desire for relief of the somatic, physical symptoms (e.g., lack of energy, aches and pains).

Although there is now nearly universal acceptance of the belief that mental health practitioners should be “culturally competent,” we can only crudely characterize the key ingredients of cultural competence, so cultural competence training has limited effectiveness. Because Asian Americans are extremely heterogeneous —there are more than fifty separate ethnic groups, including Pacific Islander Americans, speaking more than thirty languages —characterizing the necessary ingredients for working with all these groups is daunting. Moreover, teaching therapists who have received cultural training to avoid the stereotyping of Asian American clients is a problem yet to be solved.

Biological research on differential response to drug treatment is an important emerging area. On average, people of Asian ancestry tend to require lower doses of many psychotropic medications, and it appears that this is at least partly a result of differences in the liver (differences due both to genes and to diet). There is great heterogeneity in the dosage needed among Asian Americans, just as there is among Euro Americans. However, there are—on average—ethnic differences that are important to keep in mind.

One of the major debates in the field is the extent to which scientifically supported treatments (for example, interpersonal psychotherapy for depression) are appropriate for ethnic minority clients if the treatments have not been specifically tested for effectiveness within those ethnic groups. So far, the evidence— based mostly on Latinos and African Americans—suggests that empirically supported treatments, when properly adjusted for culture, have effects with ethnic minorities that are comparable to those achieved with whites. Some practitioners rail against such treatments, viewing them as “cookie cutter therapies” that are applied blindly, with ethnocentric assumptions built in. Others, I think correctly, argue that empirically supported treatments are usually flexible systems that can be successfully adapted by a truly culturally competent therapist. The key is to preserve the major effective ingredients of the therapy while at the same time culturally adapting the details of delivery in a way that fits the cultural values of individual clients.

People with mental health problems are often stigmatized in the U.S, but, on the whole, this sort of stigmatizing is even stronger among immigrants from Asian countries. Yet, certain ethnically-targeted agencies, such as Asian Pacific Family Center, have successfully engaged Asian Americans with mental health problems. So, although the ascendancy of the idea of cultural competence resulted in part from scientific and clinical research, it also resulted from the way that Asian American clients voted with their feet. They fled culturally incompetent agencies and embraced ethnically sensitive agencies where they felt at home, culturally respected and understood.

—Richard Tsujimoto, professor of psychology


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